On Cancer: Recognizing and Managing Cancer-Related Fatigue

William Breitbart, Acting Chair of the Department of Psychiatry and Behavioral Sciences and Chief of the Psychiatry Service at Memorial Sloan Kettering

Fatigue is one of the most common and distressing effects of the cancer experience and can interfere with your daily functioning and quality of life.

The American Society of Clinical Oncology (ASCO) recently adopted new recommendations for the screening, assessment, and care of cancer-related fatigue. Published in the Journal of Clinical Oncology, the guidelines emphasize the need for oncologists to recognize the symptoms and address the causes of fatigue in their patients. Experts now recommend that all patients with cancer be evaluated for fatigue after completing primary treatment and be offered specific information on how to manage it.

William Breitbart, Acting Chair of the Department of Psychiatry and Behavioral Sciences and Chief of the Psychiatry Service, was on the panel of experts that developed the guidelines. He answered our questions about fatigue and suggested strategies that may help.

What are the causes of cancer-related fatigue?

Cancer-related fatigue is often triggered by chemotherapy, radiation, and some biologic therapies used to treat the disease. Complications of cancer or cancer treatment — such as anemia, a problem with your endocrine or thyroid function, or low testosterone levels — can also induce fatigue. In addition, remaining inactive and immobile for long periods of time can cause you to become deconditioned and result in fatigue.

Tumors themselves may cause fatigue by consuming many of the body’s nutrients and secreting small proteins called cytokines that cause inflammation. The effects of fatigue may be compounded by preexisting or newly acquired health conditions such as lung, heart, or kidney problems, or by emotional issues such as anxiety or depression.

In addition, certain medications given to control some of the symptoms of cancer — such as painkillers, antidepressants, sleep aids, or drugs to control anxiety or nausea — can sometimes cause sedation and fatigue.

Do some symptoms raise the risk of developing fatigue?

Yes. Certain symptoms tend to be synergistic in terms of how they affect people with cancer. So-called “symptom clusters” include uncontrolled pain, insomnia, and intractable nausea, and left untreated they not only may become more severe but also may worsen your fatigue. You and your physician should be aware of these symptoms and try to address them at their onset.

Can fatigue be treated?

Rest alone typically does not restore energy in someone who has cancer-related fatigue. However, treating the underlying cause of fatigue will often make you feel better. It’s important to report your symptoms to your doctor so that he or she can identify and address the possible root of the problem.

For example, if you are anemic, your physician can boost your red blood cells with a blood transfusion or medication. Your doctor may recommend that you stop taking a medicine that is known to cause fatigue or replace it with something else. Relieving pain and nausea will reduce fatigue, and for some people, replenishing nutritional or vitamin deficiencies may be helpful.

Given the multiple factors contributing to cancer-related fatigue, interventions should be tailored to your specific needs.

Does fatigue manifest itself differently in people with early-stage cancer versus those with advanced disease?

There are some differences. For example, we often see a pattern of fatigue in people who receive chemotherapy. They will typically feel well for a day after the treatment, and then be quite fatigued for a few days after that. They may feel less tired over the days that follow, then recover and feel pretty good until their next treatment.

However, people with advanced disease who are on prolonged treatment tend to endure a more chronic or constant state of fatigue.

It may be helpful for some patients to use a psycho-stimulant drug such as amphetamine, Ritalin, or modafinil on those days when fatigue interferes with the ability to function or work. However, if fatigue lingers, you may find it necessary to boost your energy every day as opposed to on an as-needed basis. Discuss your options with your physician to determine what will work best for you.

Is it normal for fatigue to persist after treatment has ended?

In most cases, fatigue is a consequence of the cancer and the cancer therapy. However, it’s not uncommon for cancer survivors to experience fatigue well after they have completed treatment and are disease free. For example, certain chemotherapies can cause long-term lung or heart toxicities or neuropathy that can persist beyond the end of treatment and make you feel fatigued.

Is there overlap between fatigue and depression?

Fatigue is often a prominent symptom of depression, but it can be difficult to tease out the differences between the two. Someone who is depressed often feels very sad and tearful, hopeless, worthless, or guilty, and very fatigued. Someone who is primarily fatigued may feel down and lack motivation, but does not tend to feel those symptoms of depression.

If you treat the depression, the fatigue often gets a lot better. There is a growing body of research on interventions that have been studied in people in active treatment and are now being evaluated in cancer survivors. One approach, called cognitive behavioral therapy, is a form of psychotherapy that can help you adapt to and work around your fatigue. The goal is to stay motivated in order to accomplish the one priority you deem most important instead of giving up on everything altogether.

What practical advice would you offer to someone having a hard time with fatigue?

When you do have energy, use that time wisely. Conserve your energy to maintain the essential things in your life. It may be spending time with your family, holding your children or grandchildren, or going to a restaurant, a movie, or the theater. Participate in those activities, even if you have to ask for help. Disconnecting yourself from those activities could leave you demoralized and isolated. We have a debt to ourselves, to living our lives, and to preserving the essence of who we are by holding on to the things that give our lives meaning.

Comments

Thanks for helping me to understand my fatigue. I'm in my 4th treatment of chemo with 4 more to go. I have stage 3 inflammatory breast cancer.

Submitted by Bill Houston | Wednesday, July 2, 2014 - 7:48 AM.

Having been on ADT for metastatic prostate cancer for the last three years, I can tell you that fatigue is my constant companion. When you lower someone's testosterone from 493 to 11, the effects are profound, and fatigue is one of the most prominent symptoms. I haven't found a way to defeat it, but I have found ways to win small battles in the ongoing war. I try to stay busy. I like to cook, so daily meal preparation or food shopping keeps me busy. On the weekends, I visit my sister and her husband, along with my other brother, and often with my nephew and/or another brother-in-law. We watch football, or swim in the pool, or just sit around and have a few beers. When I am involved socially, it really helps to ward off the fatigue, at least until I get back home later that evening. When I go shopping, or do some cooking, I sometimes find it extremely difficult to stay awake, and sometimes I find it impossible to stay awake. So I give in, take a nap, wake up a little refreshed, and carry on.

Fatigue is never going to leave me, and that much I am sure of. However, I strive mightily to avoid feeling that I am in a chronic untenable situation with it, so I play "rope a dope" with fatigue. I sometimes let it punch itself out on me, and then come out swinging, and force myself to stand up, to walk around, to be socially engaged, or to go out somewhere and do something, even if it's only to go for a walk. When my granddaughter and my daughter visit for a few hours, I never feel too fatigued to play with my little sweetie, even though I am near collapse and am forced to take one of my many "crash naps" after she leaves. It is so worth it!

Prior to starting therapy with one of the smart, kind, and caring psychiatrists at MSKCC, I was totally caving in to the fatigue at every opportunity, and believing that since I couldn't do all the things I used to be able to do before, then I would do as close to nothing as possible. Lots of naps. Lots of dwelling on my cancer. Lots of feelings of futility and hopelessness. Not good for living any sort of normal life at all. I am currently taking an antidepressant, and still see my therapist every few months, just for an unbiased opinion of my emotional and intellectual state. So far, I am doing really well, and enjoy my life on its terms, instead of imagining my pre-cancer life as the what should be the current normal, and getting depressed because it isn't. Having cancer, and having treatment related side effects is the new normal, but I try to cope with it as such, instead of whining to myself about how things used to be, and will never be again. It works for me. There is joy and pleasure to be gleaned from life, regardless of my medical conditions, and there are many. I just turned 66 yesterday, and in response to one of my birthday well wisher's hope that I should have a good day, I replied that "any day you wake up above the lawn is a good day", and I still stand by that.

Your statement that when you do have energy to use that time wisely is so true, and I try to adhere to that religiously. If you have energy, then use it, instead of letting it go to waste by doing things such as sitting in the recliner watching television, or surfing the web looking for non-existent cures for your condition. Accept your reality, instead of trying to wish it away.

Bill, thank you so much for sharing your experience and words of wisdom! It is helpful to learn how you have made adjustments to continue enjoying life.

Submitted by Rick Davis | Thursday, July 31, 2014 - 8:51 PM.

Bill - I did 27+ months of ADT so have the T-shirt! Daily exercise is so important - both aerobic and resistance. It not only helps with fatigue but combats muscle and bone loss.
There are several clinical studies showing the relevance of exercise for ADT - take a look under the research tab at www.medafit.org &/or feel free to e-mail me.
If you are an MSKCC patient, I strongly recommend the classes offered by Donna Wilson; you can also watch her videos - http://www.mskcc.org/cancer-care/survivorship/videos-survivors/exercise-survivors
Onwards & upwards, rd

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